Dialysis

Dialysis
Intervention
Patient receiving dialysis
ICD-9-CM	39.95
MeSH	D006435
MedlinePlus	007434

In medicine, dialysis (from Greek dialusis,"διάλυσις", meaning dissolution, dia, meaning through, and lysis, meaning loosening or splitting) is a process for removing waste and excess water from the blood and is used primarily as an artificial replacement for lost kidney function in people with kidney failure.^[1] Dialysis may be used for those with an acute disturbance in kidney function (acute kidney injury, previously acute renal failure) or progressive but chronically worsening kidney function—a state known as chronic kidney disease stage 5 (previously chronic renal failure or end-stage renal disease). The latter form may develop over months or years, but in contrast to acute kidney injury is not usually reversible and dialysis is regarded as a "holding measure" until a kidney transplant can be performed or sometimes as the only supportive measure in those for whom a transplant would be inappropriate.^[2]

The kidneys have important roles in maintaining health. When healthy, the kidneys maintain the body's internal equilibrium of water and minerals (sodium, potassium, chloride, calcium, phosphorus, magnesium, sulfate). The acidic metabolism end-products that the body cannot get rid of via respiration are also excreted through the kidneys. The kidneys also function as a part of the endocrine system, producing erythropoietin, calcitriol and renin. Erythropoietin is involved in the production of red blood cells and calcitriol plays a role in bone formation.^[3] Dialysis is an imperfect treatment to replace kidney function because it does not correct the compromised endocrine functions of the kidney. Dialysis treatments replace some of these functions through diffusion (waste removal) and ultrafiltration (fluid removal).^[4]

History

Arm showing tubes

A Dutch physician, Willem Johan Kolff, constructed the first working dialyzer in 1943 during the Nazi occupation of the Netherlands.^[5] Due to the scarcity of available resources, Kolff had to improvise and build the initial machine using sausage casings, beverage cans, a washing machine, and various other items that were available at the time. Over the following two years, [1943-1945] Kolff used his machine to treat 16 patients suffering from acute kidney failure, but the results were unsuccessful. Then, in 1945, a 67-year-old comatose woman regained consciousness following 11 hours of hemodialysis with the dialyzer, and lived for another seven years before dying from an unrelated condition. She was the first-ever patient successfully treated with dialysis.^[5] Dr. Nils Alwall modified a similar construction to the Kolff kidney by enclosing it inside a stainless steel canister. This allowed the removal of fluids, by applying a negative pressure to the outside canister, thus making it the first truly practical device for hemodialysis. Alwall treated his first patient in acute kidney failure on September 3, 1946.

Principle

A hemodialysis machine

Dialysis works on the principles of the diffusion of solutes and ultrafiltration of fluid across a semi-permeable membrane. Diffusion is a property of substances in water; substances in water tend to move from an area of high concentration to an area of low concentration.^[6] Blood flows by one side of a semi-permeable membrane, and a dialysate, or special dialysis fluid, flows by the opposite side. A semipermeable membrane is a thin layer of material that contains holes of various sizes, or pores. Smaller solutes and fluid pass through the membrane, but the membrane blocks the passage of larger substances (for example, red blood cells, large proteins). This replicates the filtering process that takes place in the kidneys, when the blood enters the kidneys and the larger substances are separated from the smaller ones in the glomerulus.^[6]

The two main types of dialysis, hemodialysis and peritoneal dialysis, remove wastes and excess water from the blood in different ways.^[2] Hemodialysis removes wastes and water by circulating blood outside the body through an external filter, called a dialyzer, that contains a semipermeable membrane. The blood flows in one direction and the dialysate flows in the opposite. The counter-current flow of the blood and dialysate maximizes the concentration gradient of solutes between the blood and dialysate, which helps to remove more urea and creatinine from the blood. The concentrations of solutes (for example potassium, phosphorus, and urea) are undesirably high in the blood, but low or absent in the dialysis solution, and constant replacement of the dialysate ensures that the concentration of undesired solutes is kept low on this side of the membrane. The dialysis solution has levels of minerals like potassium and calcium that are similar to their natural concentration in healthy blood. For another solute, bicarbonate, dialysis solution level is set at a slightly higher level than in normal blood, to encourage diffusion of bicarbonate into the blood, to act as a pH buffer to neutralize the metabolic acidosis that is often present in these patients. The levels of the components of dialysate are typically prescribed by a nephrologist according to the needs of the individual patient.

In peritoneal dialysis, wastes and water are removed from the blood inside the body using the peritoneum as a natural semipermeable membrane. Wastes and excess water move from the blood, across the peritoneal membrane, and into a special dialysis solution, called dialysate, in the abdominal cavity.

Types

There are three primary and two secondary types of dialysis: hemodialysis (primary), peritoneal dialysis (primary), hemofiltration (primary), hemodiafiltration (secondary), and intestinal dialysis (secondary).

Hemodialysis

In hemodialysis, the patient's blood is pumped through the blood compartment of a dialyzer, exposing it to a partially permeable membrane. The dialyzer is composed of thousands of tiny hollow synthetic fibers. The fiber wall acts as the semipermeable membrane. Blood flows through the fibers, dialysis solution flows around the outside of the fibers, and water and wastes move between these two solutions.^[7] The cleansed blood is then returned via the circuit back to the body. Ultrafiltration occurs by increasing the hydrostatic pressure across the dialyzer membrane. This usually is done by applying a negative pressure to the dialysate compartment of the dialyzer. This pressure gradient causes water and dissolved solutes to move from blood to dialysate, and allows the removal of several litres of excess fluid during a typical 4-hour treatment. In the United States, hemodialysis treatments are typically given in a dialysis center three times per week (due in the United States to Medicare reimbursement rules); however, as of 2005 over 2,500 people in the United States are dialyzing at home more frequently for various treatment lengths.^[8] Studies have demonstrated the clinical benefits of dialyzing 5 to 7 times a week, for 6 to 8 hours. This type of hemodialysis is usually called "nocturnal daily hemodialysis", which a study has shown a significant improvement in both small and large molecular weight clearance and decrease the requirement of taking phosphate binders.^[9] These frequent long treatments are often done at home while sleeping, but home dialysis is a flexible modality and schedules can be changed day to day, week to week. In general, studies have shown that both increased treatment length and frequency are clinically beneficial.^[10]

Hemo-dialysis was one of the most common procedures performed in U.S. hospitals in 2011, occurring in 909,000 stays (a rate of 29 stays per 10,000 population).^[11]

Peritoneal dialysis

Schematic diagram of peritoneal dialysis

In peritoneal dialysis, a sterile solution containing glucose (called dialysate) is run through a tube into the peritoneal cavity, the abdominal body cavity around the intestine, where the peritoneal membrane acts as a partially permeable membrane. The peritoneal membrane or peritoneum is a layer of tissue containing blood vessels that lines and surrounds the peritoneal, or abdominal, cavity and the internal abdominal organs (stomach, spleen, liver, and intestines).^[12] Diffusion and osmosis drive waste products and excess fluid through the peritoneum into the dialysate until the dialysate approaches equilibrium with the body's fluids. Then the dialysate is drained, discarded, and replaced with fresh dialysate.^[13]

This exchange is repeated 4-5 times per day; automatic systems can run more frequent exchange cycles overnight. Peritoneal dialysis is less efficient than hemodialysis, but because it is carried out for a longer period of time the net effect in terms of removal of waste products and of salt and water are similar to hemodialysis. Peritoneal dialysis is carried out at home by the patient, often without help. This frees patients from the routine of having to go to a dialysis clinic on a fixed schedule multiple times per week. Peritoneal dialysis can be performed with little to no specialized equipment (other than bags of fresh dialysate).

Hemofiltration

Hemofiltration is a similar treatment to hemodialysis, but it makes use of a different principle. The blood is pumped through a dialyzer or "hemofilter" as in dialysis, but no dialysate is used. A pressure gradient is applied; as a result, water moves across the very permeable membrane rapidly, "dragging" along with it many dissolved substances, including ones with large molecular weights, which are not cleared as well by hemodialysis. Salts and water lost from the blood during this process are replaced with a "substitution fluid" that is infused into the extracorporeal circuit during the treatment.

Hemodiafiltration

Hemodiafiltration is a combination of hemodialysis and hemofiltration.

Intestinal dialysis

In intestinal dialysis, the diet is supplemented with soluble fibres such as acacia fibre, which is digested by bacteria in the colon. This bacterial growth increases the amount of nitrogen that is eliminated in fecal waste.^[14][15][16] An alternative approach utilizes the ingestion of 1 to 1.5 liters of non-absorbable solutions of polyethylene glycol or mannitol every fourth hour.^[17]

Starting indications

The decision to initiate dialysis or hemofiltration in patients with kidney failure depends on several factors. These can be divided into acute or chronic indications.

• Indications for dialysis in the patient with acute kidney injury are summarized with the vowel acronym of "AEIOU":^[18]
  1. Acidemia from metabolic acidosis in situations in which correction with sodium bicarbonate is impractical or may result in fluid overload.
  2. Electrolyte abnormality, such as severe hyperkalemia, especially when combined with AKI.
  3. Intoxication, that is, acute poisoning with a dialyzable substance. These substances can be represented by the mnemonic SLIME: salicylic acid, lithium, isopropanol, magnesium-containing laxatives, and ethylene glycol.
  4. Overload of fluid not expected to respond to treatment with diuretics
  5. Uremia complications, such as pericarditis, encephalopathy, or gastrointestinal bleeding.

Indications for chronic dialysis: Chronic dialysis may be indicated when a patient has symptomatic kidney failure and low glomerular filtration rate (GFR). Between 1996 to 2008 there was a trend to initiate dialysis at progressively higher estimated GFR, eGFR. A review of the evidence shows no benefit or potential harm with early dialysis initiation, which has been defined by start of dialysis at an estimated GFR of greater than 10ml/min/1.73².Observational data from large registries of dialysis patients suggests that early start of dialysis may be harmful.^[19] The most recent published guidelines from Canada, for when to initiate dialysis, recommend an intent to defer dialysis until a patient has definite kidney failure symptoms, which may occur at an estimated GFR of 5-9ml/min/1.73².^[20]

Some reason for dialysis initiation include difficulty in medically controlling fluid overload or serum potassium. If a patient has intractable kidney failure symptoms or signs, start of dialysis may be recommended at eGFR levels above 10ml/min/1.73²

Dialyzable substances

Characteristics

Dialyzable substances have following properties:

1. low molecular mass
2. high water solubility
3. low protein binding capacity
4. prolonged elimination (long half life)
5. small volume of distribution

Substances

• Ethylene glycol
• Procainamide
• Methanol
• Isopropyl alcohol
• Barbiturates
• Lithium
• Bromide
• Sotalol
• Chloral hydrate
• Ethanol
• Acetone, Atenolol
• Theophylline
• Salicylates

Dialysis provision in the United Kingdom

The National Health Service provides dialysis in the United Kingdom. In England the service is commissioned by NHS England. About 23,000 patients use the service each year.^[21]

See also

Materials and methods

• Thomas Graham (chemist), the founder of dialysis and father of colloid chemistry
• Dialysis tubing
• List of US dialysis providers

Medical applications

• Apheresis, also known as plasmapheresis, is another extracorporeal technique that selectively removes specific constituents from blood
• Hemodialysis
• Peritoneal dialysis
• Acute kidney failure
• Kidney failure
• Nephrology
• Chronic kidney disease
• Hepatorenal syndrome

References

^[1][2][3][4]

External links

• Machine Cleans Blood While You Wait—1950 article on early use of Dialysis machine at Bellevue Hospital New York City—i.e. example of how complex and large early dialysis machines were
• Home Dialysis Museum—History and pictures of dialysis machines through time
• Introduction to Dialysis Machines—Tutorial describing the main subfunctions of dialysis systems.

1. ↑ 12)Al-Mosawi, A. J. (2004). Acacia gum supplementation of a low-protein diet in children with end-stage renal disease. Pediatric Nephrology, 19(10), 1156-1159
2. ↑ 13)Al Mosawi, A. J. (2007). The use of acacia gum in end stage renal failure. Journal of tropical pediatrics, 53(5), 362-365
3. ↑ 14) Ali, A. A., Ali, K. E., Fadlalla, A. E., & Khalid, K. E. (2008). The effects of gum arabic oral treatment on the metabolic profile of chronic renal failure patients under regular haemodialysis in Central Sudan. Natural product research, 22(1), 12-21
4. ↑ 15)Miskowiak, J. (1991). Continuous Intestinal Dialysis for Uraemia by Intermittent Oral Intake of Non-Absorbable Solutions: An Experimental Study. Scandinavian journal of urology and nephrology, 25(1), 71-74